1. Ask most people what do they wish for for the last chapter of their life.

2. And what most people will say is they hope it

3. comes at the end of a long happy life.

4. And they hope it happens at home surrounded by the people who love them.

5. And they hope that they're free of pain and fear.

6. And for the majority of people, it turns out not to be what they get.

7. In the United States, for instance, over 60% of people

8. die in hospitals, not at home, even if they tried

9. to ask to have that arrangement made.

10. And when they're at the hospital, the opposite of that

11. surrounded with the familiar and the loved ones, right?

12. Think of the times you've been in a hospital-- incredibly disorienting,

13. right?

14. Nothing familiar about it.

15. People bustling in, and you get to know one nurse,

16. and then another one comes on call.

17. In one of the most compelling studies that I've read,

18. a bioethicist by the name of Dan Sulmasy did an amazing study

19. where he went into a hospital and, with the permission of patients,

20. put a camcorder at the side of the bed right at eye level

21. to capture what a patient sees in the bed as they lay dying.

22. He ran the camcorder until the death and afterwards and then

23. reviewed the footage from dozens of patients.

24. And he said, reviewing that footage was one of the saddest moments of his life.

25. For what he saw as he looked from the patient's perspective

26. was an empty room.

27. 90% of the time, the patient was alone.

28. And this isn't because the health care providers weren't caring.

29. It's because it's an institution.

30. Right?
31. So what people want is to be at home, but they're at the hospital.

32. What they want to be is surrounded by loved ones,

33. but they're surrounded by strangers, and sometimes, not surrounded at all.

34. Why does this happen if so many of us want

35. something so basic as a good death?

36. Why does medicine so often get in the way?

37. Well, one of the issues is a really fascinating issue

38. that medical anthropologists talk about which

39. is sort of the culture of medicine, again, in many countries.

40. When you ask medical care professionals what their mission is,

41. it's to save lives.

42. But the metaphor that's used often turns out into a kind of warrior-like one--

43. that the culture is to battle death.

44. Now think about what that implies.

45. It's got a good side and a bad side.

46. The good side is that when we can save your life, that's awesome.

47. You want that warrior by your side and not giving up on you.

48. Right?

49. But when it becomes clear, or should become clear,

50. that we're moving to not whether you'll die but how you'll die.

51. Having a warrior who identifies with death as failure

52. is not who you want at your side.

53. So doctors as a gross generalization, but still as a true generalization,

54. are incredibly aversive to death.

55. But if the culture is aversive about death,

56. that sets up a really bad scenario.

57. So often, patients who want to be, as it were, shepherded through

58. to the transition from, we're trying to keep you alive, to let's

59. talk about how to die, where you're not going to be abandoned.

60. And you will be surrounded by loved ones.

61. And we will be here to take care of your pain and make sure

62. that you're not afraid as much as possible-- what a friend of mine who's

63. a hospice volunteer calls a midwife to your death just like the other book

64. end of life.

65. We need help.

66. Think of it this way.

67. When you're dying, you've never done it before, right?

68. So don't you think you might need somebody

69. who has an experience with how to do what you

70. might expect what's going to happen?

71. And the family, often, at least in many countries, we don't die at home,

72. so it's new to the family as well.

73. So to have somebody who's aversive about death isn't what you need.

74. Now some physicians and nurses are wonderful about this, especially

75. people in the palliative care movement which

76. has grown leaps and bounds fortunately.

77. And they often are trying their hardest to get the patient and the family,

78. often, to acknowledge and understand and make that transition to now we're

79. talking about making this a good death.

80. OK?

81. And they find the patients or the family pushing back.

82. That in the midst of fear and anxiety and being scared,

83. they say do everything.

84. They don't want to give up hope, oftentimes,

85. because family think that giving up hope is somehow giving up caring.

86. And they need the doctors and nurses to say no.

87. You still can care for your loved one.

88. But what your caring looks like right now

89. is not asking for more interventions.

90. It's asking for support, surrounding, and help in dying.

91. Thank you.